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Abstract

Background: Hand hygiene is a vital aspect of infection control and as such requires monitoring. Assessing compliance with hand hygiene and providing healthcare workers with feedback on their performance is important in any hospital hand hygiene improvement program. Aim: to investigate the degree of conformance with hand hygiene by healthcare personnel in a private tertiary hospital. Methods: a structured observational study to monitor conformance with hand hygiene during provision of patient care in a private health care facility in south west Nigeria, before and after institution of a hand-hygiene improvement campaign. Results: A total of 311 healthcare workers were observed from June 2015 to June 2016 with 1476 opportunities for hand hygiene. Improvements in hand hygiene occurred with a 33 % increase in compliance after contact with body fluids, 18% after the removal of gloves, 39% after touching the patient, 27% before performing an invasive procedure and 30% before touching the patient. Preoperative Nurses were 7.48 times more likely than the general population to wash their hands before patient contact [CI=3.1-18.73, X2=25.38], Critical care Units Staff were 0.34 times more likely to comply after contact with body fluids [CI=0.16-0.75, X2=6.15]. Conclusion: Measuring hand hygiene compliance is a veritable tool in hand hygiene compliance. Sustained educational programs and reminders serve to improve hand hygiene.

Introduction

Hand hygiene is an important aspect of Infection prevention
and control (IPC) and its compliance requires measurement.
Monitoring conformance with established hand hygiene
parameters and providing healthcare personnel with results
concerning their performance is a vital part of hand hygiene in
the hospital setting. Observational surveys done covertly is one
of the means of determining compliance. [1]

The transmission of microorganisms from the hands of hospital
personnel is a huge source of infections and these can be readily
prevented by staff conforming with laid down hand washing
protocols such as the World Health Organization’s (WHO) five
moments of hand hygiene. This is because unwashed personnel’s
hands are the most common means for the transmission of
pathogens from patient to patient and within the healthcare
environment. [2]

Hand hygiene is therefore the easiest means for preventing the
spread of pathogens with huge antimicrobial resistance potential
and reducing rates of healthcare-associated infections. However,
healthcare workers conformance with optimal practices has
been observed to be low in most settings. [3]

These infections acquired in the hospital are a major cause of morbidity as well as mortality. Some studies have also shown
that hand washing practices are persistently poor and sub
optimal. It has also been challenging to show that hand washing
practices can be easily improved and this has been attributed
to difficulties associated with behavior modification among
hospital staff. [4]

Adherence, with best practices for hand hygiene remains
low but factors responsible for non-adherence have been
identified and corrective actions proposed in some studies. The
present guidelines propose the use of alcohol-based hand rub
formulations where feasible in the absence of running water as
the new standard of care, thus needing a system change in most
hospitals. [5]

As a result, healthcare personnel education and encouragement
have been proposed by some as key to change hand hygiene
behavior in order to enhance conformance in hospitals. Improvement in compliance is associated with reduced infection
rates and antimicrobial resistance.

Rational

Consistent hand hygiene is the sole most efficient tool
available to prevent nosocomial infections. Daily hand hygiene
opportunities and compliance for in-patients in our hospital are
currently unknown. Hand hygiene literature is scarce in private
tertiary hospitals in Nigeria. In order to establish a trend in
compliance, a study thus needs to be performed and information
on hand hygiene practice in such facilities will be collected and
act as a baseline for developing interventions and assessing
progress in compliance with best practices.

Aim

This study was intended to investigate the degree of conformance
with hand hygiene and use of gloves by various categories of
HCWs in a private tertiary hospital, and the factors that influence
compliance to hand hygiene.

Objectives

Analyze the trends of hand hygiene practices over a 12 month
period so as to determine behavioral patterns for hand hygiene
and factors that contributed to compliance improvement or
otherwise.

Methods

Study setting

The study was carried out at the Babcock University Teaching
Hospital, a Private facility located in a rural setting. It is a 170
bed facility that caters for the health needs of undergraduate
students of the institution and the immediate host community.

Study design

This was a structured observational study where we monitored
conformance with hand hygiene during patient care at a teaching
hospital in a sub-urban setting in south west Nigeria, before
and during implementation of a hand-hygiene campaign. Two
facility wide surveys were done six monthly with analyses of
hand hygiene behavior in relation to profession, indication and
shift.

From June 2015 till June 2016, HCWs in the hospital were
covertly observed. The trained covert observer noted the
number of opportunities for hand hygiene and the number of
occasions for which the HCW complied with appropriate action.
Adherence to standard precautions was evaluated.

Each event for hand hygiene or application of alcohol hand
rubs or soap and water before or after patient contact was
regarded as a hand hygiene opportunity. Any personnel who
decontaminated his or her hands immediately after contact with
a patient and then directly attended another patient without
touching any object for example equipment, door handles or
any other patient was considered to have complied with hand
hygiene practice in relation to the second patient, same for the other moments of hand hygiene as determined by WHO. Hand
hygiene compliance was expressed as a percentage, according
to the formula.

Sample size determination

Assuming a compliance rate of 30% the sample size formula
N=Z2pq//d2 gave a figure of 322 opportunities.

Data analysis

This was done using EPI INFO version 3.5.1 (CDC Atlanta)
software. The Chi Square for Odds ratio was to test associations
between variables and the Confidence Interval set at 95% with
the level of significance being p< 0.05.

Data safety

All data collection was performed in a discrete manner and all
information obtained were kept in the Principal Investigators
computer and accessed only via a secure password.

Ethical approval was obtained from the Babcock University
Teaching Hospital.

Results

In all 311 healthcare workers were observed over a two year period from June 2015 till June 2016. Most of these personnel were from the Surgery Department (30.2%) followed by the Critical Care Unit (17%) and the Emergency Department (16.7%). The year 2015 had 176 staff observed; there was a decline to 135 staff in 2016 due to a high staff turnover. The predominant staff observed were the Circulating Nurses (46.3%), next were the Anesthetists (10%), Surgeons and Residents (9%). Senior Nurses and Pre-operative Nurses were 8 and 7.4% respectively [Table 1].

Variables

Frequency

Percent

A/E

52

16.7

CCU

53

17.0

Medicine

59

19.0

Paediatrics

15

4.8

Surgery

94

30.2

GOPD

26

8.4

Dental

12

3.9

Total

311

100

2015

176

56.6

2016

135

43.4

Compliance rate

812/1476

55.01

Total

311

100

Anesthesiologist

31

10

Senior Nurse

25

8.0

Circulating Nurse

144

46.3

Surgeon

28

9.0

Medical Student

2

0.6

Resident

28

9.0

Dental Technologist

2

0.6

Pre-operative Nurse

23

7.4

Medical Officer

3

1.0

Post-operative Nurse

18

5.8

Surgical technologist

7

2.3

Total

311

100

Table 1: Distribution of participants by wards, years and specialty.

Regarding compliance with hand hygiene the Pre-operative Nurses were 7.48 times more likely than the general population to wash their hands before patient contact [CI=3.1-18.73, X2=25.38], Senior Nurses were also 3.8 times more likely to observe hand hygiene before contact with patients [CI=1.2- 16.11, X2=7.66]. The only group that observed hand hygiene after patient contact was again the pre-operative nurses [CI=1.79-14.8, X2=10.73]. The Pre-operative Nurse was also found to be 4.04 times more likely to perform hand hygiene before performing an invasive procedure [CI=1.27-29.3, X2=4.96] [Table 2].

Personnel

Hand Hygiene Activity(%)

p value

AOR

95% CI

×2

Before contact with the patient

Compliant

Non-compliant

Pre-op Nurse

13 (56.5)

10 (43.5)

0.00

7.48

3.1-18.73

25.38

42 (14.7)

244 (85.3)

Resident Doctor

13 (52)

12 (48)

0.08

0.48

0.21-1.12

3.13

194 (69.3)

86 (30.7)

Circulating Nurse

16 (11.3)

126 (88.7)

0.006

0.42

0.22-0.78

7.66

39 (23.4)

128 (76.6)

Senior Nurse

22 (88)

3 (12)

0.02

3.8

1.2-16.11

5.1

185 (66)

95 (34)

After Contact with the patient

Pre-op Nurse

18 (78.3)

5 (21.7)

0.001

4.78

1.79-14.8

10.73

123 (44.3)

164 (55.7)

After Contact with body fluids

Anesthesiologist

9 (42.9)

12 (57.1)

0.00

0.13

0.05-0.33

24.0

193 (85.8)

32 (14.2)

Pre-op Nurse

20 (95.2)

1 (4.8)

0.08

4.71

0.83-101

2.68

182 (80.9)

43 (19.1)

After the use of gloves

Senior Nurse

22 (88)

3 (12)

0.02

3.8

1.16-6.94

6.14

185 (66)

95 (34)

Pre-op Nurse

19 (82.6)

4 (17.4)

0.11

2.37

0.83-8.33

2.47

188 (66.7)

94 (33.3)

Before Conducting an Invasive Procedure

Pre-op Nurse

20 (90.9)

2 (9.1)

0.03

4.64

1.27-29.3

4.96

187 (68.2)

87 (31.8)

Resident

15 (53.6)

13 (46.4)

0.05

3.92

0.21-1.00

0.46

183 (68.3)

85 (31.7)

Surgeon

24 (85.7)

4 (14.3)

0.05

2.78

1.0-9.63

3.65

183 (68.3)

85 (31.7)

AOR = Adjusted Odds Ratio, CI = Confidence Interval, X2= Chi Square

Table 2: Compliance of healthcare personnel with hand hygiene.

In terms of departmental compliance the Critical care Units Staff were 0.34 times more likely to comply after contact with body fluids [CI=0.16-0.75, X2=6.15]. The Internal Medicine Department, Surgery and Emergency rooms were also compliant with hand hygiene after patient contact [CI=1.03-3.25, 1.15- 3.02 and 0.20-0.76 respectively]. In addition the surgeons were 2.05 times more likely to perform hand hygiene before carrying out an invasive procedure [CI=1.15-3.72, X2=5.97] and also 0.59 times to wash hands after the removal of gloves before performing another task [CI=0.35-0.98, X2=4.27] [Table 3 and Figure 1].

Discussion

Conformance with hand hygiene is an effective preventive measure with respect to hospital infection control. Many of such infections are caused by pathogens transmitted from one patient to another by the hands of health care workers who have not washed their hands between patient care or who do not practice control measures such as use of hand disinfection with alcohol based preparation or glove use. [6-8]

The average compliance rates with hand hygiene recommendations varies between hospital wards, among professional categories of health-care workers, working conditions and definitions used in various studies. Compliance is estimated as being less than 50% which is less than the 55% obtained in our facility. [6]

Education, feedback intervention and patient awareness programs have had varying results with improvement in conformance. With the introduction of wall located dispensers containing an alcohol-based waterless hand washing antiseptic, significantly higher hand washing rates among health care workers have been observed. [9]

Our data and those of other researchers show that hands become progressively contaminated with commensal flora and potential pathogens during routine care, we therefore need to identify activities that are at higher risk for hand contamination and step up surveillance in those instances. [10]

Limited access to hand hygiene supplies, such as sinks, soap, or alcohol-based hand rub solutions are challenges towards conformance. This also includes the inconvenient location of hand wash sinks that make hand washing a mentally challenging task for health care workers and places a burden on them. [11]

Physicians adherence to hand hygiene is tied to workload constraints and possibly years of practice and exposure to educational programs. Strengthening a positive work culture attitude toward hand hygiene and reinforcing the conviction that each staff can influence group behavior may also improve adherence among physicians. [12]

Our data indicate that hand hygiene practice in the Critical Care Unit is sub-optimal as a consequence of a break in communication of infection control recommendations, insufficient promotion and enforcement of agreed research-based infection control practices, and a deficiency in infection control education. The current methods of communicating infection control recommendations have a limited effect on compliance rates in the CCU and are not evaluated adequately. [13]

We observed distinctly high rates of compliance of nurses towards hand hygiene which is also similar to the findings of researchers in Taif, Saudi Arabia where they identified team work and leadership as key factors that enhanced compliance in their cohort of nurses studied. Indeed it has been proven that nursing personnel are more compliant with hand hygiene than physicians as evidenced by a study from Nair et al in India who showed that nursing students were more compliant with hand hygiene when compared to medical students. [14,15]

Hand hygiene is recommended before performing invasive procedures and after overt or covert microbial contamination. Guidelines must be clear and easy for HCW’s in our environments to follow for them to become the norm in practice. Thus guidelines are needed that are easy to apply and reproducible across hospital such as in our cases that have a high volume and traffic of patients. [16]

In addition, the use of reminders or asking patients to remind staff of the need to conduct hand washing can have a sustained effect in enhancing compliance. The feedback of performance in our scenario leads to an improvement in compliance. This has been described in other settings and shown to increase the levels of compliance, however if the feedback is not repeated regularly, then this effect is not sustained. [17]

The provision of hand rubs close to patient beds has led to an increase in the frequency with which staffs cleanse their hands. Multipronged approaches which combine education with written material, reminders and continued feedback of performance can have an important effect on hand washing compliance and rates of hospital-acquired infection. [5,17,18]

Good hand hygiene also reduces the spread of infections in the community. This is important because there is a dynamic flow between the hospital and the community. Alcohol-based hand sanitizers therefore come in handy in providing a convenient easy and cheap means of compliance. [20]

Direct contact between patients and healthcare workers who are transiently contaminated with nosocomial pathogens is believed to be the primary route of transmission for several organisms and can lead to patients becoming colonized or infected. A review of hand hygiene studies by the World Health Organization (WHO) found that baseline compliance with hand hygiene among healthcare workers was on average only 38.7%. [21,22]

Another study that adapted a multipronged approach on hand hygiene education showed that with system change, feedback evaluation and continuous reminders there can be up to 60% improvement in hand hygiene compliance rates as well as a reduction in MRSA infections in the hospital. [23,24]

The use of covert observers such as in our hospital has regularly pointed to nurses as the drivers of hand hygiene compliance. Dan and co-workers also showed nurses to have higher compliance rates and suggested them as ambassadors of hand hygiene programs. Getting it right with healthcare workers will markedly reduce the rates of HAI’s. [25-28]

Interventions: after the use of covert observers to collect data we presented our preliminary findings to the University Teaching Hospital at the Global Hand Washing Day. We also played video demonstrations of good hand hygiene techniques to the hospital staff, made posters on hand hygiene available all over the hospital and ensured that alcohol hand rubs were in sufficient quantity in all the wards. We put in place a system where once the alcohol hand rubs were exhausted the Infection control link nurses were notified and they made sure the in house pharmacy re stocked immediately.

Recommendations

From our findings we recommend the use of covert non identified observers on a periodic basis to assess the rates of hand hygiene compliance in our hospitals and the feedback of these results to departments and units as a means of inducing behavior change with regards to hand hygiene. With concerted efforts the compliance rates may improve over time.